Clinical Coder and Summariser

Job description

Job responsibilities

Job Summary:

We are seeking a meticulous and detail-oriented Clinical Coder and Summariser to join our dynamic team at Castle Partnership. This role is essential in ensuring that patient records are accurately coded, summarised, and maintained in line with NHS and practice guidelines. The successful candidate will play a crucial role in supporting the clinical and administrative teams, contributing to the overall efficiency of the practice.

Key Responsibilities:

• Clinical Coding:
• Accurately code clinical information from patient records, including diagnoses, procedures, and treatments, using the appropriate coding systems (e.g., Read Codes, SNOMED).
• Ensure coding is completed promptly to facilitate patient care and practice reporting requirements.
• Maintain up-to-date knowledge of coding guidelines and standards, and ensure compliance with NHS requirements.
• Identify and correct any discrepancies or errors in patient records related to coding.
• Summarising Patient Records:
• Review and summarise incoming patient records, ensuring all relevant medical information is accurately captured and entered into the practices clinical system.
• Organize and file electronic and paper medical records appropriately.
• Ensure the completeness and accuracy of patient records, supporting clinicians in delivering high-quality patient care.
• Liaise with other healthcare providers to obtain missing information when necessary.
• Data Quality and Reporting:
• Assist in maintaining the integrity and quality of patient data, ensuring it is up-to-date and accurate.
• Participate in regular audits of clinical coding and summarising practices to ensure compliance with internal and external standards.
• Support the generation of reports and data analysis for clinical and managerial use.
• Team Collaboration:
• Work closely with GPs, nurses, and administrative staff to ensure effective communication and collaboration within the practice.
• Provide training and guidance to other staff members on clinical coding and summarising processes when needed.

Person Specification

Qualifications

Essential

• GCSE Grade A to C in English and Maths (or equivalent)
• Any qualification in clinical coding, or equivalent from working experience

Desirable

• Accredited Clinical Coding Qualification
• Degree educated

Experience

Essential

• Experience of working in General Practice
• Experience in clinical coding and/or summarising

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Employer details

Employer name

Castle Partnership

Address

Gurney Surgery

40 Fishergate

Norwich

Norfolk

NR3 1SE

Employer's website

https://www.castle-partnership.co.uk/ (Opens in a new tab)